02/16/2024

SURGERY
PAIN MANAGEMENT IN SURGICAL PATIENTS

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Prepared by: ASHENAFI ANTENEH
&
ASHENAFI TEKLU
CONTENTS

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 Introduction

 Etiology

 Pathophysiology

 Diagnosis/ pain assessment

 Pharmacological management

 Nonpharmacological management

 Monitoring

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PAIN

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 pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such damage.
 The concept of total pain, refers to the global nature of pain perception not
only as a physical ailment but that it has a psychological, spiritual and social
consequences.

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PAIN

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 Pain and physical discomfort is common in the surgical patient as a result
of injury, invasive procedures, or pre-existing illnesses.
 80% patients who undergo surgical procedures experience acute
postoperative pain
 75% with postoperative pain report the intensity as moderate, severe, or
extreme.
 Less than half report adequate postoperative pain relief.

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PAIN

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 Unrelieved pain may contribute to patient discomfort, anxiety,
exhaustion, disorientation, agitation, tachycardia, increased
myocardial oxygen consumption, pulmonary dysfunction, impairs
immune function, which slows healing and increase susceptibility to
infections and dermal ulcers.

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ETIOLOGY

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 Tissue damage - nociceptive pain
 Nerve damage - neuropathic pain

 Psychological factors - psychogenic pain

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PATHOPHYSIOLOGY

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Nociceptive pain
 Usually considered as acute pain, is either:

 Somatic: localize directly to the site of injury (arising from skin, bone, joint,
muscle, or connective tissue) or
 Visceral: diffuse, poorly differentiated, referred pain (arising from internal
organs such as the large intestine or pancreas).

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PATHOPHYSIOLOGY

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 Nociception can be expressed in terms of stimulation (transduction),
transmission, perception, and modulation.
 Stimulation of nociceptors (sensory nerve cells) is the 1 st step leading to the
sensation of pain.
 These receptors are found in both somatic and visceral structures and are
activated by mechanical, thermal, and chemical factors.

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CLASSIFICATION

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 Postoperative pain can be divided into acute pain and chronic pain
 Acute pain - experienced immediately after surgery (up to 7 days)

 Chronic Pain - which lasts more than 3 months after the surgery.

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ASSESSMENT OF PAIN

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 A variety of tools and assessment scales have been advocated to
document the degree of pain.
 Pain is highly subjective- must use patient-oriented approach.

 Comprehensive patient history & physical examination must be

obtained.
 Assessment of the patient experiencing pain is the cornerstone to
optimal pain management.

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COMPONENT OF WILDA APPROACH PAIN
ASSESSMENT

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1. Word
2. Intensity
3. Location
4. Duration
5. Aggravating/ alleviating factors

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VISUAL ANALOGUE SCALE (VAS)

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 universal adoption of a Classified using a standard 0 to 10 (no pain – worst
possible pain) scale.
1. Mild pain- rating of 1-3,
2. Moderate pain- rating of 4-6,
3. Severe pain- reaching 7-10 and is associated with worst outcome.

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TREATMENT
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TREATMENT

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 Goal of treatment
 To minimize pain & provide reasonable comfort at the lowest effective

analgesic dose.
 With chronic pain, goals may include rehabilitation & resolution of

psychosocial issues.

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 TREATMENT: PHARMACOLOGIC

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 Pain is prevented and/or treated using various pharmaceutical agents.
 These medications can be divided into four general categories:

1. Non opioid analgesics

2. Opioid analgesics

3. Local anesthetics

4. Analgesic adjuvant drugs

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TREATMENT: PHARMACOLOGIC

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1. Non opioid analgesics - aspirin, acetaminophen, naproxen, NSAIDS and
cyclooxygenase inhibitor/cox 2 inhibitor
2. Opioid analgesics:
 weak opioids - Codeine and Tramadol

 Strong opioids - (morphine, Diamorphine ,Pethidine,

Piritramide ,hydromorphone, fentanyl, oxycodone, hydrocodone).
3. Local anesthetics - lidocaine, bupivacaine
4. Analgesic adjuvant drugs - tricyclic antidepressants, antihistamines,
benzodiazepines, steroids, phenothiazines, anticonvulsants, clonidine.

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 WHO Analgesic
Ladder

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TREATMENT: PHARMACOLOGIC

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 WHO analgesic ladder
 Step 1: Non opioid ±adjuvant : ASA, Paracetamol, NSAIDs/COX-2s ±
adjuvant.
 Step 2: Opioid for mild to moderate pain ± nonopioid ± adjuvant: Codeine,
Tramadol, oxycodone, ± NSAIDs/COX– 2s, ± adjuvants.

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TREATMENT: PHARMACOLOGIC

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 WHO analgesic ladder
 Step 3: Opioid for moderate to severe pain, ± non opioid, ± Adjuvant:
Oxycodone, Morphine, Hydromorphine, Fentanyl, methadone, ± NSAIDs/COX
– 2s, ± adjuvants.
 Step 4: Nerve block, epidurals, PCA pump, neurolytic nerve blocks.

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TREATMENT: PHARMACOLOGIC

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 Non opioid analgesia
 Diclofenac: 50mg PO TID

 Ibuprofen: 400-600mg TID

 Paracetamol: 1 gm Po QID

 Weak Opioids

 Tramadol: 50-100mg q8h-q6h. Maximum dose is 400mg

 Low-dose morphine

 strong Opioids

 Morphine 2.5-5 mg Q4hrs.

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SEVERITY OF PAIN MILD PAIN MODERATE PAIN SEVERE PAIN

Type of Surgery Myringotomy Reduction of nasal fracture Wisdom teeth extraction

Submucous resection
Excision of nasal or aural polyps
Biopsy of oral lesions
Excision of tongue tie
Dilatation and Curettage
Hysteroscopy
0ther minor gynaecological
surgery
Excision of breast lump
Removal of other lumps and
bumps
Orchidopexy
Circumcision
Lymph node biopsy
Toenail surgery
Cataract surgery
Tonsillectomy Wide excision of breast lump with axillary
Adenoidectomy clearance
Removal of dental bone plates and Open hernia repair
wires Laparoscopic hernia repair
Surgical removal of wisdom tooth Laparoscopic cholecystectomy
Cone biopsy of cervix Haemorrhoidectomy
Termination of pregnancy Varicose vein surgery
Laparoscopic tubal ligation Anal fissure dilatation or excision
Marsupialisation Arthroscopic surgery
Cystoscopy Removal of orthopaedic implants
Herniotomy
Ligation of Varicose veins
Ligation of Hydrocoele
Vasectomy
Excision of thyroid nodule
Bunion surgery
Dupuytren‟s contracture surgery
Carpel tunnel surgery
Excision of ganglion
Excision of chalazion
SEVERITY OF PAIN MILD PAIN
S
Preop analgesia Oral NSAIDs/Cox-2inhabitor
+ Paracetamol
Intraop analgesia Wound infiltration with LA
+/- IV fentanyl
Postop analgesia Oral NSAIDs/Cox-2 inhibitor
In Recovery Room + Paracetamol (if not given
preop)
MODERATE PAIN
Oral NSAIDs/cox-2 inhibitor +
Paracetamol
Wound infiltration with LA
and/or Peripheral Nerve/plexus
block or
Single shot spinal +/- IV
fentanyl
Oral NSAIDs/Cox-2 inhibitor (if
not given preop)
Oral or IV Tramadol Oral
Oxycodone IV fentanyl (titrated
to effect)
SEVERE PAIN
Oral NSAIDs/Cox-2 inhibitor +
Paracetamol
Wound infiltration with LA and/or
Peripheral Nerve/plexus block or
Single shot spinal +/- IV fentanyl
Oral NSAIDs/Cox-2 inhibitor (if not
given preop) Oral or IV Tramadol Oral
Oxycodone IV fentanyl (titrated to
effect)
ADJUVANTS FOR PAIN

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 Anti-Depressants and Anticonvulsants - for neuropathic pain, which may
present as burning, pricking, paresthesia or sharp, shooting pain.
 Amitriptyline: 25mg PO at night. Increase dose as needed.

 Carbamazepine: 200 mg PO at night. Increase dose as needed.

 Gabapentin: 300 mg PO at night. Increase dose as needed.

 Corticosteroids - used as adjuvant treatment if neuropathic pain is suspected

to be due to nerve compression e.g. by tumor or inflammation.
 Dexamethasone: 4 mg daily

 Prednisone: 40-60mg daily

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TREATMENT: PHARMACOLOGIC

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 Muscle relaxants/Anxiolytics: are used as an adjuvant for skeletal muscle
spasm and anxiety- related pain
 Diazepam: 5mg orally, 2-3 times per day.

 Antispasmodics: are helpful in relieving visceral distension pain and colic.

 Hyoscine Butylbromide: 10mg three times /day PO or IM; can be increased

to 40mg three times/day.

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TREATMENT: NONPHARMACOLOGIC

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 Techniques proven to be useful in acute pain management:
1. Psychological approaches:
 Cognitive methods-training in coping methods or behavioural
instruction prior to surgery, reduces pain and analgesic use.
 Distraction- effective in procedure-related pain in children.

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TREATMENT: NONPHARMACOLOGIC

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 Hypnosis and relaxation-inconsistent evidence of benefit in the
management of pain.
 Music- reduction in postoperative pain and opioid
consumption.
 Pre-operative information- effective in reducing procedure-
related pain.

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TREATMENT: NONPHARMACOLOGIC

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2. Complementary therapies and other techniques: including
massage, acupuncture, Tens(transcutaneous electrical nerve
stimulation), hot and cold packs.

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MANAGEMENT OF TREATMENT RELATED
COMPLICATIONS

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 Opioid toxicity/ overdose
 appear when the administered dose of morphine is more than what is required
for pain relief, or when the pain is not morphine-responsive, yet dose is
escalated progressively.
 Signs - delirium, myoclonus and drowsiness

 Treatment – dose reduction

– administration of opioid antagonists (Naloxone)

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MANAGEMENT OF TREATMENT RELATED
COMPLICATIONS

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 Indications for Naloxone
1. RR < 8/minute
2. RR < 12/minute, difficult to rouse, cyanosis
3. RR < 12/minute, difficult to rouse, SaO2 <90%
 Dose – dilute naloxone 400 micrograms to 10ml with 0.9% saline.

– Give 0.5ml (20 micrograms) IV every 2min until respiratory status is

satisfactory.
– Further boluses may be necessary because naloxone is shorter-acting
than morphine.

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MONITORING

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 Respiratory Rate
 Blood Pressure
 Pulse Rate
 Pain Score
 Sedation Score

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REFERENCE

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 Standard treatment guideline for general hospitals in Ethiopia 4th
edition,2020.
 REGINA FINK, RN, PHD, AOCN , Pain assessment: the cornerstone
to optimal pain management.

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 THANK YOU
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February 16, 2024